Lead Order Form Mailer FormatMailer FormatBifold - WhiteBifold - PinkBifold - BlueType of Mailer(Required)Type of MailerMedicareTurning 65Final ExpenseLong Term CareMailer Piece Code Lead Delivery Method(Required)Lead Delivery MethodScan and ShipTL ManagerBoth ($20 per thousand)DemographicsIf you ran your own count, enter query number: OR fill out demographics belowAge Date of Birth Income Range Omit PO BoxesDo you want to exclude PO Boxes?YesNoOther ZipCodes, SCF, County and/or States:Order QuantitiesNumber to Mail(Required)Total Cost If quantity is 500-999, add $50 flat set up fee. If under 500, add $100 set up. Does not include shipping/handling or tax for TX orders. Cost per thousand and final cost are subject to change.Duplicate List OptionsDuplicate List Options 8 1/2 X 11 Printed List $25/M Email List in Excel or CSV $25/M Labels $25/M Additional OptionsAdditional Options Print Phone #'s (where available) on card - $10/M Street Sequence on duplicate list - $3/M Print DOB month/year on duplicate list - $20/M Select Homeowners Only - $10/M Select by Gender - $3/M Notes and Special InstructionsNotes and InstructionsBilling and/or Shipping AddressCompany name Email(Required) Name(Required) First Last Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pay By(Required)Pay ByCredit CardCheckNote: We will contact you for card information. Order is subject to zip code availability under our 90 day file protection policy I have seen a Mail Piece Sample:I have seen a Mail Piece Sample:YesNo